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The Program of All-Inclusive Care for the Elderly (PACE) is a managed care program that enables elderly individuals who are certified to need nursing facility care to live as independently as possible.
PACE participants receive a comprehensive service package which permits them to live at home while receiving services. This prevents institutionalization. The PACE organization must provide all Medicaid covered services, in addition to other services determined necessary by PACE for the individual beneficiary. The PACE program becomes the sole source of services for Medicaid and/or Medicaid/Medicare eligible enrollees.
The PACE program is a fully capitated managed care benefit. The PACE organization assumes full financial risk for participants’ care without limits on amount, duration, or scope of services. CMS establishes and pays the Medicare capitation and each State establishes and pays the Medicaid capitation. When the enrollee receives Medicaid and Medicare, the PACE organization receives a Medicaid capitation payment and a Medicare capitation payment.
1. The PACE program is regulated through a three-party agreement among Centers for Medicare and Medicaid Services (CMS), North Carolina Department of Health and Human Services through the Division of Medical Assistance, and the PACE organization.
2. The PACE organization administers the PACE program and is responsible for enrolling individuals into the PACE program.
ISSUED 02-01-08 – CHANGE NO. 07-08
(II.A.)
3. The PACE program allows North Carolina to use Medicaid funds to provide home and community based services to Medicaid recipients who require institutional care (placement in a nursing facility), but for whom care can be provided cost-effectively and safely in the community with PACE services. Institutional care for PACE is defined as SNF level.
4. A PACE organization is required to provide a specified set of services that includes:
• Interdisciplinary team case management;
• Adult day health program;
• Skilled nursing care;
• Primary care physician services;
• Specialized therapies;
• Personal care services;
• Nutrition counseling;
• Meals;
• Transportation, and
• Prescriptions.
5. If at any time, PACE determines an individual can no longer be cared for in the home, the PACE organization may place the PACE recipient in another health care setting for a short period of time, or if necessary, it can be a permanent placement. Temporary and/or permanent placement in another health care setting such as a nursing facility does not change an individual’s PACE enrollment status or capitation rate. The PACE organization is responsible for payment of cost of care.
1. An individual must be living in the approved geographic area of the PACE organization;
2. Be at least 55 years old or older;
3. Be determined by the PACE organization to be able to be cared for safely in the community;
4. Meet the State’s eligibility criteria for nursing home level of care.
1. Applications for PACE enrollment are initiated and processed by the PACE organization. Once PACE approves enrollment, the applicant must sign a Participant Enrollment Agreement. PACE enrollment is always the first day of the month following the month the Participant Enrollment Agreement is signed and received by the PACE organization.
REISSUED 11/01/11 – CHANGE NO. 17-11
(II.C.)
2. Once enrolled for PACE, the recipient is enrolled for the next year unless he terminates enrollment. PACE recipients are re-assessed annually by the PACE organization.
3. “Lock-In” Provision
"Lock-in" means once enrolled in PACE, health care services will be provided through the PACE organization. Services will be approved by the members of the PACE Multidisciplinary Team. If a PACE recipient receives medical services that have not been approved by the PACE Multidisciplinary Team, the recipient may be personally responsible for paying the cost of those services. If a PACE recipient receives medical services from a non-PACE medical provider without prior authorization (with the exception of Emergency Services), the recipient may be liable for the full cost of those services.
4. When an individual enrolls in PACE, he is ineligible for any other Medicare plans or any other Medicaid services, programs/categories, or optional benefits, except for MQB. Refer to XI below.
1. The county must determine Medicaid eligibility for individuals requesting PACE services following the rules and regulations for Aged, Blind and Disabled Medicaid, including the need for a FL-2.
2. DMA makes a prospective capitated monthly payment to the PACE organization for each eligible Medicaid participant. The county must determine Medicaid eligibility for individuals requesting PACE services.
3. Because of the exclusively frail population served by PACE and the immediate need for PACE services, it is imperative that Medicaid applications and requests for PACE services be expedited. Eligibility must be entered by the pull date in order for the PACE capitated payment to begin the next calendar month. Failure to enter PACE information by these EIS dates will result in denied payments to the PACE organization. PACE organizations are aware that application processing times can be reduced dramatically by assisting the county in obtaining financial and other eligibility information. Communication between the DSS and the PACE organization is crucial to attain priority processing of Medicaid eligibility for PACE services.
REVISED 11/01/11 – CHANGE NO. 17-11
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